Tilmicosin toxicity: a case of accidental human tilmicosin injection managed with calcium, high-dose insulin and intravenous lipid emulsion therapy

Background. In the context of the current COVID-19 pandemic, there has been renewed interest in the drug hydroxychloroquine. However, clinicians should be aware of the dangers of hydroxychloroquine intoxication, an insufficiently studied condition. Case Report. We present a case of autointoxication with 20 g hydroxychloroquine in a 35-year-old woman. Cardiac monitoring showed ventricular arrhythmias for which high-dose midazolam and propofol were initiated, resulting in a brief normalization of the cardiac rhythm. Because of the reoccurrence of these arrhythmias, intravenous lipid emulsion was administered with fast cardiac stabilization. Treatment with continuous norepinephrine, potassium chloride/phosphate, and sodium bicarbonate was initiated. On day 6, she was extubated and after 11 days, she was discharged from the hospital without complications. Conclusion. Since high-quality scientific evidence is lacking, treatment options are based on experience in chloroquine toxicity. Activated charcoal is advised if the patient presents early. Sedation with diazepam, early ventilation, and continuous epinephrine infusion are considered effective in treating severe intoxication. Caution is advised when substituting potassium. Despite the lack of formal evidence, sodium bicarbonate appears to be useful and safe in case of QRS widening. Intravenous lipid emulsion, with or without hemodialysis, remains controversial but appears to be safe. As a last resort, extracorporeal life support might be considered in case of persisting hemodynamic instability.

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High-Dose Insulin and Intravenous Lipid Emulsion Therapy for Cardiogenic Shock Induced by Intentional Calcium-Channel Blocker and Beta-Blocker Overdose: A Case Series

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2013.08.135 ◽

2014 ◽

Vol 46 (4) ◽

pp. 486-490 ◽

Cited By ~ 33

Author(s):

Bruce Doepker ◽

William Healy ◽

Eric Cortez ◽

Eric J. Adkins

Keyword(s):

Cardiogenic Shock ◽

Calcium Channel ◽

Calcium Channel Blocker ◽

Beta Blocker ◽

Lipid Emulsion ◽

Channel Blocker ◽

Case Series ◽

High Dose ◽

Intravenous Lipid Emulsion

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The use of high-dose insulin therapy and intravenous lipid emulsion to treat severe, refractory diltiazem toxicosis in a dog

Journal of Veterinary Emergency and Critical Care ◽

10.1111/vec.12053 ◽

2013 ◽

Vol 23 (3) ◽

pp. 321-327 ◽

Cited By ~ 17

Author(s):

Barbara L. Maton ◽

Erin E. Simmonds ◽

Justine A. Lee ◽

Amy J. Alwood

Keyword(s):

Insulin Therapy ◽

Lipid Emulsion ◽

High Dose ◽

Intravenous Lipid Emulsion

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Evaluating the Effects and Safety of Intravenous Lipid Emulsion on Haloperidol-Induced Neurotoxicity in Rabbit

BioMed Research International ◽

10.1155/2014/949262 ◽

2014 ◽

Vol 2014 ◽

pp. 1-9 ◽

Cited By ~ 5

Author(s):

Mohammad Moshiri ◽

Amir Hooshang Mohammadpour ◽

Maryam Vahabzadeh ◽

Leila Etemad ◽

Bahram Memar ◽

...

Keyword(s):

Mortality Rate ◽

Normal Saline ◽

Pupil Size ◽

Lipid Emulsion ◽

High Dose ◽

Tissue Samples ◽

Intravenous Lipid Emulsion ◽

The Third ◽

Death Time ◽

Complications And Mortality

There are many reports on the effect of intravenous lipid emulsion (ILE) as an antidote in drugs related toxicities. We determined the effects of ILE on neurotoxicity of haloperidol (HA), a highly lipophilic antipsychotic, as a model of antipsychotics poisoning. We used six groups of five male rabbits. Two groups received distilled water intravenously followed by infusions of either 18 mL/kg of normal saline or ILE 20%, after 30 minutes. The third group received 18 mL/kg of normal saline after HA (2.6 mg/kg) administration. The three other groups received ILE 20% solution (6, 12, and 18 mL/kg) following HA injection. Catalepsy scores, temperature, pupil size, and mortality rate were measured at 0, 0.5, 1, 2, 3, 4, 8, and 24 hours after HA administration began. Blood and tissue samples were taken from all animals at 24 hours or at death time for biochemical, cell count, and pathological studies. ILE reversed cataleptic scores, miotic pupils, and hypothermia of HA intoxication much faster than normal saline (P<0.001). Biochemical complications and mortality rate of the animals were significantly higher in the HA + 18 mL/Kg ILE group. ILE reversed sings of HA neurotoxicity; however, synergistic effect of high dose of ILE and HA increased complications and mortality.

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High-dose intravenous lipid emulsion affecting successful initiation of continuous venovenous hemofiltration and extracorporeal membrane oxygenation

Clinical Toxicology ◽

10.1080/15563650.2017.1341633 ◽

2017 ◽

Vol 56 (2) ◽

pp. 149-150 ◽

Cited By ~ 3

Author(s):

Jonathan H. Sin ◽

Andrew Tom ◽

Alexander Toyoda ◽

Nathalie Roy ◽

Bryan D. Hayes

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Lipid Emulsion ◽

High Dose ◽

Continuous Venovenous Hemofiltration ◽

Intravenous Lipid Emulsion ◽

Membrane Oxygenation

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Effects of high-dose, intravenous lipid emulsion on laboratory tests in humans: a randomized, placebo-controlled, double-blind, clinical crossover trial

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2018-0430 ◽

2018 ◽

Vol 56 (12) ◽

pp. 2047-2057 ◽

Cited By ~ 1

Author(s):

Kasper M. Petersen ◽

Niklas R. Jørgensen ◽

Søren Bøgevig ◽

Tonny S. Petersen ◽

Thomas B. Jensen ◽

...

Keyword(s):

Laboratory Tests ◽

Lipid Emulsion ◽

Specific Reference ◽

High Dose ◽

Test Results ◽

Total Calcium ◽

Double Blind ◽

Mean Values ◽

Intravenous Lipid Emulsion ◽

Analytical Platforms

AbstractBackgroundIntravenous lipid emulsion (ILE) is used to treat drug poisonings. The resultant hyperlipemia may affect laboratory tests but the consequences are poorly characterized. In a clinical trial we therefore investigated the effects of ILE on laboratory tests analyzed on common analytical platforms (Roche®cobas 8000 and SYSMEX®flow-cytometry).MethodsTen healthy participants each completed 4 trial days (two with ILE and two with placebo). ILE (5.25 mL/kg) was administered from 12.5 to 30 min from baseline. At 0, 30 and 60 min, blood samples were drawn for measurement of 20 analytes. We investigated the effects of ILE on analyte levels and frequencies of exceedance of predefined analyzer hemolysis (H) or lipemia (L)-index cut-offs and test-specific reference change values (RCVs) on ILE-days. If the results were blocked due to exceedance of index values, we manually extracted the results.ResultsSixteen out of 20 tests were blocked because H- or L-index cut-offs were exceeded on ILE-days. Differences in analyte levels between ILE- and placebo-days above the RCV were observed for aspartate aminotransferase, total calcium, lactate dehydrogenase (LDH), sodium and neutrophils. Mean values outside the normal range after ILE were observed for LDH (219 U/L), sodium (135.3 mmol/L) and total calcium (2.1 mmol/L).ConclusionsILE-infusion caused report failure of nearly all laboratory tests performed on a cobas 8000-platform, but it was possible to manually retrieve the results. For most test results – particularly alkaline phosphatase, bilirubin, phosphate and carbamide – the consequences of ILE were marginal, and the effects of ILE were reduced at the 60-min timepoint.

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